How Do I Request Medical Records?

To review a possible medical malpractice case or nursing home injury or neglect case at Duncan Law we must have the injured person’s medical records reviewed by an expert witness.  These are usually an expert nurse and/or a physician. For a medical expert to give a thorough review of your case it is important they have the opportunity to review the medical records.

To obtain a copy of the medical records you must request the records from the medical care provider. To provide these medical records to you, your health care provider must follow government privacy laws called HIPAA.  HIPAA is the Health Insurance Portability and Accountability Act of 1996.

First, you must qualify to receive the medical records. If you are the patient requesting your medical records, you can sign a HIPAA release and receive your medical records. If you are not the patient, you must have a formal release signed by the patient or have the legal authority to obtain these records.  The legal authority is usually granted by a power of attorney document properly executed by the patient (not just a hand written note signed by the patient). If the patient is incapacitated, you may have to obtain a legal guardianship or a court order to acquire the records. If the patient has died you must be the executor of their will or be appointed administrator of their estate by the clerk of the court or a judge.

Filling Out A Document

Second, after qualifying to receive the medical records you should make a written request to the medical care provider to provide the medical records. The medical provider may have these records stored electronically offsite away from their physical location, so it may take several days to obtain these records. If the records are stored offsite, the medical care provider should provide the records to you within 10 calendar days.

If the records are available at the facility, they should be able to have a copy made for you within 24 hours of your request. Do not expect to walk into the medical facility and they make you copies while you wait.

When you request the records, the staff may ask you why do you want a copy of your medical records? First, you are not required to answer that question. It is your medical records and you do not have to answer that question. However, any time you ask for medical records, especially from a doctor’s office, it raises flags and alerts the doctor to a possible problem. The staff will usually inform the doctor or nursing home administrator of the request and they go into “defensive mode”. In the past, some medical providers have been known to illegally change the medical records to “cover up” a mistake they have made.  Be aware this could happen. If the medical records are on site, you may ask the person in charge of medical records to pull the records so that you may look at the records on site before they are copied.  Once you have reviewed the records, you may then ask for copies.  After receiving the records, review the records and determine if any changes were made. If changes were made, notify your attorney immediately and dispute this with the medical facility.

Many medical providers will “discourage” you from obtaining the medicals by charging you an outrageous price per page to “copy” these medical records. Some providers will attempt to charge you a $1.00 per page.  If you have 600 pages due to an extended hospital or nursing home stay that could become very expensive. Fortunately, in North Carolina, there is a state law that prohibits excessive copy fees.  It is North Carolina General Statute  90?411, which states:

“A health care provider may charge a reasonable fee to cover the costs incurred in searching, handling, copying, and mailing medical records to the patient or the patient’s designated representative. The maximum fee for each request shall be seventy?five cents (75 cents) per page for the first 25 pages, fifty cents (50 cents) per page for pages 26 through 100, and twenty?five cents (25 cents) for each page in excess of 100 pages, provided that the health care provider may impose a minimum fee of up to ten dollars ($10.00), inclusive of copying costs.”

Once you’ve received your medical records contact your medical malpractice attorney or nursing home injury lawyer and provide them with the records so they can be appropriately reviewed.

What is the Statute of Limitations for a Nursing Home Abuse and Neglect Case?

If you or a loved one has been injured or severely neglected in a nursing home, the timeframe to seek damages against the facility and staff is limited by law in North Carolina to three years from the last act of malpractice. In other words, you must file a lawsuit prior to the three year deadline or you are forever barred from suing the facility and staff.

It helps to understand how nursing home abuse and neglect cases are viewed by the legal system. A nursing home abuse and neglect case is considered a malpractice case. As defined by the N.C. General Statutes, malpractice arises from the performance of or failure to perform professional services. N.C. Gen. Stat. § 1-15(c) limits the timeframe to three years from the last act of malpractice. Only in extremely rare cases of nursing home abuse and neglect would the timeframe to file a lawsuit be extended to four years from the last act of malpractice.

Therefore, if you believe you or your family member has been a victim of nursing home abuse or neglect, you should seek legal advice as soon as possible. Most attorneys need six months to review the case and obtain the required expert witnesses (usually doctors and nurses) prior to filing a lawsuit.

Preventing Nursing Home Injury of a Loved One

One of the best ways to protect your loved one from abuse or neglect in a nursing home is frequent and unplanned visits to the facility to see the patient. This will allow you to see how care is provided by a number of the staff members at various times of the day and night. And although it is often difficult, a physical exam of the family member can often reveal injuries that have been hidden by clothing or blankets. Unreported cuts, bruises and bed sores are often discovered by the family member during a physical exam. If the patient has gauze, patches or other coverings of the skin, you should ask why it is there and ask to be present the next time the covering is changed.

Help your loved one by being aware of these signs of abuse and neglect and being attentive to their care. Contact us if we can help assist you in any way.

What is Sepsis?

Sepsis, or septicemia is a potentially fatal illness that occurs when the body reacts to infection that has spread throughout the body. Sepsis is most commonly seen in the elderly or in young children, but may occur at any age.

Symptoms

Symptoms of sepsis usually include, but aren’t limited to: fever, increased heart rate, decreased urine output, pain in joints, confusion and low blood pressure. Sepsis may be seen in patients who have had pneumonia, urinary tract infections, ruptured appendix and meningitis. It is critical that if signs of sepsis are seen to notify the appropriate medical personnel.

Causes

The most common cause for sepsis is an infection that spreads. The body’s reaction to infection is inflammation. Usually the body will create the necessary chemicals to fight the inflammation and infection. However, in patients who become septic their entire body may become inflamed causing the body to overreact. This overreaction causes small blood clots to form throughout the body. The body works harder to break up these clots but when unable to do so the body’s organs lack the necessary oxygen and begin to fail.

Treatment

Early detection of sepsis is key to survival. If identified early enough, sepsis may be treated with the use of intravenous fluids (IVs), antibiotics and removal or sanitation of the infected area and source. Without proper treatment sepsis can become severe and eventually lead to septic shock causing death.

According to the National Institute of General Medical Sciences , “every year, severe sepsis strikes about 750,000 Americans. It’s been estimated that between 28 percent and 50 percent of these people die—far more than the number of U.S. deaths from prostate cancer, breast cancer, and AIDS combined.”

If you believe a loved one has died or been seriously injured by the failure of a medical facility to properly diagnose sepsis or other illness, contact us today to see how we may be able to help.

For further information on sepsis visit:

U.S. National Library of Medicine
The Mayo Clinic